On an airplane long ago—fifteen or twenty years—I turned and discovered Robert McNamara in the next seat. McNamara needs no introduction for people over, say, sixty but—shockingly—probably does for most of the American population. Robert Strange McNamara, I should therefore explain for anyone middle-aged or younger, was secretary of defense for seven years under Presidents John F. Kennedy and Lyndon Johnson. He must have been in his early eighties at the time of our encounter.
McNamara was an architect of the Vietnam War, which remains the defining experience of my generation, for those who served in it as well as those who protested against it, along with those who only listened to the music. The year was 1975 when the helicopters took off from the roof of the American embassy in Saigon, bearing the last Americans; a few of the embassy staff and others who had been loyal to us to the end (and who therefore thought it would be unwise to hang around); and miscellaneous Vietnamese, desperate to get out for a variety of good reasons. The years since have hardly been boring. And maybe AIDS, Iraq, 9/11, and whatever else fate has lined up to keep us amused will make Vietnam seem small in hindsight. But I doubt it, don’t you? And I don’t think that’s just generational vanity.
McNamara himself turned against the war—though never publicly or explicitly—and resigned as defense secretary in 1968 to become head of the World Bank. Our plane was going to Denver, and I asked him what was taking him there. He said that he was meeting a female friend at the Denver airport and then heading for Aspen. It seems that when his wife died he had sponsored in her memory one of a chain of primitive huts on a cross-country ski trail between Aspen and Vail. Now he was going to ski the trail and stay in the huts with his lady friend. He told me this, then beamed, like my pal the judge in the pool.
Well, life is unfair, but let’s not get carried away.
Longevity is not a zero-sum game. A longer life for Robert McNamara doesn’t mean a shorter life for you or me or the average citizen of Vietnam. He did that damage long ago, and won’t be doing any more. In fact, he seems to have spent the gift of a long life trying to make amends—mainly, as he described his recent agenda to me, by flying around the world to conferences where the world’s suffering is deplored. Nevertheless.
To get to that view of things, though, I had to suppress an irrational feeling that McNamara had won big in a game he shouldn’t have been. Yes, life is unfair, and never more so than in how much of itself it gives to different people. Deaths of children and young adults are mourned with special pain, and the very, very old are celebrated. But death at any age between about sixty and about ninety doesn’t rate a second glance as you flip through the obituaries. (Oh yes, you do.) Death anywhere between sixty and ninety is considered a “normal” life span, even though the ninety-year-old got 50 percent more life than the sixty-year-old.
What’s more, of all the gifts that life and luck can bestow—money, good looks, love, power—longevity is the one that people seem least reluctant to brag about. In fact, they routinely claim it as some sort of virtue—as if living to ninety were primarily the result of hard work or prayer, rather than good genes and never getting run over by a truck. Maybe the possibility that the truck is on your agenda for later this morning makes the bragging acceptable. The longevity game is one that really isn’t over till it’s over.
Between what your parents gave you to start with—genetically or culturally or financially—and pure luck, you play a small role in determining how long you live. And even if you add a few years through your own initiative, by doing all the right things in terms of diet, exercise, sleep, vitamins, and so on, why is that to your moral credit? Extending your own life expectancy is the most selfish motive imaginable for doing anything. Do it, by all means. I do. But for heaven’s sake, don’t take a bow and expect applause.
This is the game that really counts. Perhaps you imagine that, as eternity approaches, the petty ambitions and rivalries of this life melt away. Perhaps they do. That doesn’t mean that the competition is over. It means that the biggest competition of all is about to start. Do you doubt it? Ask yourself: what do you have now, and what do you covet, that you would not gladly trade for, say, five extra years? These would be good years, of cross-country skiing between fashionable Colorado resorts, or at least years when you could still walk and think and read. You would still be a player in whatever game you spent your life playing: still invited to faraway conferences about other people’s problems, if you ever were; still baking your famous chocolate chip banana bread for the family, if your life followed a less McNamarish course. What would you trade for that? Or, rather, what wouldn’t you trade? Okay, you’d give up years for the health and happiness of your children. What else? Peace in the Middle East? A solution to global warming? A cure for AIDS? These negotiations are secret, mind you. No one will know if you selfishly choose a few extra years for yourself over an extra million or two for planet Earth. We’ll posit that you’re a good person, though, and that to spare the earth from a couple of the Four Horsemen, you’d accept a shorter span for yourself.
Few people ever have the opportunity to make an explicit choice between extra years of life for themselves and some noble cause or other. Among those who do are soldiers. People who volunteer for military service or act bravely in battle consciously risk giving up most of their biblically allotted three score and ten, and for some who do, this choice is both wise and generous beyond belief. Unfortunately, every war has at least two sides, and at most one of them is the good side. The math suggests that, in the course of history, most of these sacrifices probably were a mistake. Robert McNamara’s years were enough to equal the life spans of four soldiers who died in Vietnam.
Anyway, enough about Robert McNamara. Back to you. Children, country, future of the world, are off the table. And, yes, these are the important things. But there are also other, less exalted things that make life sweet. The baby boom generation in America is thought to have found something approaching genuine happiness in material possessions. Remember that bumper sticker HE WHO DIES WITH THE MOST TOYS WINS? This was thought to be a mordant encapsulation of the baby boom generation’s shallowness, greed, excessive competitiveness, and love of possessions. And it may well be all of these things. It’s also fundamentally wrong. Is there anything in the Hammacher Schlemmer catalogue—or even listed on realtor.com—for which you would give up five years? Of course not. That sports car may be to die for, but in fact you wouldn’t. Die for it, that is. What good are the toys if you’re dead? “He who dies last”—he’s the one who wins.
Competitive consumerism wasn’t invented by boomers, or yuppies, as they’re sometimes called. What’s the difference between a boomer and a yuppie? (Sounds like we’re building up to a punch line here, but there’s no joke. Sorry.) Boomers—short for baby boomers—are Americans born during the “baby boom” that followed the end of World War II, as millions of couples tried to make up for lost time. Boomers include everybody born in the years between 1946—the earliest date at which a serviceman returning from Europe after the war could come home and join his wife in producing a baby—and 1964, the last year anyone could reasonably use celebration of the Allied victory in World War II as a reason for having sex.
Yuppies—short for “young urban professionals”—refers to a subset of boomers: the trendsetters who moved from the suburbs where they grew up into tastefully restored town houses in the inner cities. The ones who first discovered Starbucks (and were the first to reject it and move on to espresso machines). The ones who—well, you know who you are. All boomers aren’t yuppies, but almost all boomers have been heavily influenced by yuppies in their lifestyle choices. In fact, the very notion of a “lifestyle”—that all the major aspects of your life (your work, your family, your clothes, your spiritual beliefs, your kitchen equipment) should be conscious decisions, or really one big conscious decision about the shape of your life—is a core yuppie value widely adopted not just by boomers but by the nation at large.
Boomers realize the ultimate folly of competitive consumerism, of course. Don’t forget: Back in the Dark Ages, we invented jogging. More important, we invented the jogging shoe: a whole industry aimed right at the boomer sweet spot. Our knees now regret it—too late, too late. A new malady was also invented to go along with the jogging shoes. That is the dreaded “pronation.” It’s been a remarkable development. No one in America was known to suffer from pronation until around 1965. Now, pronation is tied with knee problems and back problems at number 17 on Esquire’s annual list of the top conversational topics to avoid. (The inventor and master of these shopping lists as commentary on lost time is David Brooks of the New York Times, who really deserves credit, if not actual royalties, for them. Fortunately for me, one of the themes of this book is that few people get what they deserve, in this life or the next one.)
The passion for Things and the hunger to acquire them are deeply rooted in yuppie culture. I win if my house is bigger than yours, or if my cell phone is smaller. Or if my laptop computer is thinner or my hiking boots are thicker. And yet all this is meaningless, isn’t it? And I don’t mean that in a spiritual or moral way. Be as greedy and self-centered as you want. The only competition that matters, in the end, is about life itself. And the standard is clear: “Mine is longer than yours.”
The oldest boomers, born in the late 1940s, are approaching seventy. Seventy! This surely was not supposed to happen. But it has happened. The early heats of the Boomer Games are already over, and they stop, mercifully, at around eighty, where the first boomers will start to arrive in 2026. Welcome to the age of competitive longevity.
So how are you doing? Let’s say you’re sixty-five. To begin with, you’re still alive, which gives you a leg up. Or are the real winners in our youth-obsessed generation the boomers who died young, like John Belushi and Janis Joplin? Well, perhaps, but you’ve already missed that boat. There may be glamour in dying in your early twenties. There is no glamour in dying in your late fifties.
The Washington Post carried an amusing article a while ago about tech billionaires facing the very real problem of what to do with their money once they’ve bought every imaginable toy up to and including the private plane and yet still have billions left. There is the Bill Gates model: They can use the money for good works. All of them do some of that—it’s hard to avoid. But at some point the logic of “mine is longer than yours” reasserts itself and you decide to spend some money trying to live forever.
The leading immortophiliac is Larry Ellison, the longtime CEO of Oracle. At the time the article was published, in April 2015, Ellison had invested more than $430 million in antiaging research. The article quotes Ellison from a book about him: “Death has never made any sense to me. How can a person be there and then just vanish, just not be there?” Actually the question is not whether death makes sense to Larry Ellison but whether Larry Ellison makes sense to death. And I’m afraid he does.
For someone born in the United States in 2013, the most recent year for which there are final figures, life expectancy is 78.8 years. That’s 76.4 years for males and 81.2 years for females. But if you’ve made it to 65, your life expectancy is 82.9 if you’re a man and 85.5 if you’re a woman. (In Katha Pollitt’s book of essays Learning to Drive, there is a vicious one called “After the Men Are Dead.”) The mortality tables are fun to play with, in a ghoulish way. The United States comes in a shameful fifty-third, behind Ireland, Bosnia, and Bermuda, among other countries. It’s not true, however, as you often hear, that they do better in Cuba than we do. Our life expectancy in the United States is 0.49 years longer than Cuba’s. And before you laugh off 0.49 years, consider that 0.49 years is just under 6 months: one last golden spring and summer with the grandchildren. How much is that worth to you?
Ellison’s quest for eternal life is likely to be disappointing. But I have an idea for him. He should redefine his goal slightly and consider the project a success if it merely achieves a measurable increase in life expectancy and not actual immortality. In fact, he’s in luck because half a billion dollars could extend the lives of many thousands, if not millions, of people if spent on such things as mosquito nets to fight malaria rather than exotic cancer treatments for people such as Larry Ellison. This has been the approach of the Bill and Melinda Gates Foundation, which has added more life-years to the planet simply by bringing the underdeveloped world a small step toward the standards of the Western world than any amount of money will ever achieve by keeping Larry Ellison alive until he turns 100 in 28 years. (My wife is former CEO of the Gates Foundation, so I may be biased here.) On the other hand, I am the beneficiary of high-tech medicine, specifically deep brain stimulation for Parkinson’s. So I have mixed feelings.
But enough about Larry Ellison. Back to you. Of course, all these life-expectancy figures are only averages. Factors that you control, such as diet, exercise, and smoking, can affect your score. So can factors that are beyond your control but are already known or knowable, such as your family health history. What most affects your own outcome, though, is the simple fact that averages are only averages. Think of this as good news: In order for the averages to work out, for every person who dies in his forties, there must be three or four who make it into their eighties.
You might compare the boomer longevity competition to a tontine. This was a macabre form of investment, popular in Europe and America in the seventeenth, eighteenth, and nineteenth centuries. In its simplest form, a group of investors would each put a certain amount of money into a pool, and the money would sit there accumulating interest until all but one of the members had died, then that one survivor would get the whole pile. There’s a very funny movie about a tontine called The Wrong Box starring Michael Caine. A tontine is the ultimate in “moral hazard,” an insurance industry term for the temptation to cause whatever it is you are insuring yourself against. For example, fire insurance encouraging fires. Or a tontine encouraging people to murder one another.
(Old moral-hazard joke: Three elderly retirees are sitting on the beach in Florida. One of them asks the other two, “What brought you here?” Second guy says, “I had a small factory up north, but it burned down in a mysterious fire. So I took the insurance money and retired to Florida.” Third guy says, “Me too. Owned a factory. Mysterious fire. Insurance money. Florida.” He turns to the first guy. “And how about you?” First guy says, “Same story, almost. My factory was wiped out in a huge tidal wave, so I took the insurance money and moved to Florida.” The other two look at each other, and finally one says, “Gosh, who do you go to for a tidal wave?”)
A tontine sounds like the kind of thing we don’t have anymore, but in fact the Social Security system is sort of like a tontine: We all put in the same fraction of our wages (with ceilings and other complications). And because you get a check every month, the amount you get back depends on how long you live. Social Security is insurance against longevity. Except that longevity is something we all want. So people who die young are doubly screwed. First, they lose those years, and second, they lose Social Security benefits.
African Americans on average live over three years less than the white population. So they are among the double losers. Women, who live longer than men, are double winners. It’s hard to think what, if anything, can be done about this. By its nature, insurance is a pooling of risks. If we could all pay in or draw out from Social Security according to our own risk profile, there would still be winners and losers, people who do dramatically better or worse (live longer or die earlier) than their profiles would predict.
And actually life itself is sort of like a tontine. The winners are the ones who outlive their friends. Even without a cash prize, we all would like to win. Life would be pretty empty without your friends. But not as empty as death.
We are born thinking that we’ll live forever. Then death becomes an intermittent reality, as grandparents and parents die, and tragedy of some kind removes one or two from our own age cohort. And then, at some point, death becomes a normal part of life—a faint dirge in the background that gradually gets louder. What is that point? One crude measure would be when you can expect, on average, one person of roughly your age in your family or social circle to die every year. At that point, any given death can still be a terrible and unexpected blow, but the fact that people your age die is no longer a legitimate surprise, and the related fact that you will die, too, is no longer avoidable.
With some heroic assumptions, we can come up with an age when death starts to be in-your-face. We will merge all sexual and racial categories into a single composite American. We will assume that there are 100 people your age who are close enough to be invited to your funeral. Your funeral chapel won’t fit 100 people? No problem. On average, half of them will be too busy decomposing to attend. As Max Beerbohm noted in his novel, Zuleika Dobson, “Death cancels all engagements.” And why 100? Because it’s easy, and also because it’s two-thirds of “Dunbar’s number,” of 150, which is supposedly the most relationships that any one set of human neurons can handle. We’re crudely assuming that two-thirds of those are about your age.
Anyway, the answer is age 63. If a hundred Americans start the voyage of life together, on average one of them will have died by the time the group turns 16. At 40, their lives are half over: Further life expectancy at age 40 is 39.9. And at age 63, the group starts losing an average of one person every year. Then it accelerates. By age 75, sixty-seven of the original one hundred are left. By age 100, three remain.
The last boomer competition is not just about how long you live. It is also about how you die. This one is a “Mine is shorter than yours”: You want a death that is painless and quick. Even here there are choices. What is “quick”? You might prefer something instantaneous, like walking down Fifth Avenue and being hit by a flowerpot that falls off an upper-story windowsill. Or, if you’re the orderly type, you might prefer a brisk but not sudden slide into oblivion. Take a couple of months, pain-free but weakening in some vague nineteenth-century way. You can use the time to make your farewells, plan your funeral, cut people out of your will, tell them to their faces that you’ve cut them out, finish that fat nineteenth-century novel that you’ve been lugging around since the twentieth century, and generally tidy up.
The government statistics on how people die are lavish and fascinating. Let’s forget for a moment that it’s a catalogue you can’t really shop from. And yet you also can’t put it down and say “No, thanks” to the whole thing. So what’s your pleasure? Or should I say, “Choose your poison”? In 2015 more than 40,000 Americans committed suicide, out of 2.5 million who died of all causes. Of all suicides, 17 percent are, indeed, by poison. (Over half are by firearms.) Women are three times as likely as men to attempt suicide, but men are four times as likely to succeed.
Of injury deaths (which include poisoning), 85 percent are accidental; 13 percent are suicide; 2 percent are homicide. Accidents have been on a roll and now rank number four among all causes of death. Within the general category of accidents, accidental overdoses, mainly of prescription drugs, recently surpassed auto accidents in killing people. Stroke, which used to be third, is now fifth.
The big two are heart disease and cancer, each of which accounts for about a quarter of the Grim Reaper’s annual take. “Chronic lower respiratory diseases” (for example, emphysema) trail at a distant third place, with only 6 percent.
Pneumonia used to be called “the old man’s friend” because it ended so many lives whose owners were finished with them. That role (though possibly not the label) has now been taken over by accidental falls. The death rate from falls nearly doubled from 30 per 100,000 in the year 2000 to nearly 60 per 100,000 in 2013.
And here’s a creepy one: The death rate due to suffocation is eight times higher for people over eighty-five than for people between the ages of sixty-five and seventy-four.
Together, cancer and heart disease account for almost half of all deaths in the United States, so choosing between these two is a good way to avoid disappointment. But an informed choice isn’t easy. Heart disease runs the spectrum from a sudden fatal heart attack while opening Christmas presents with your grandchildren to years of bedridden decline. A stroke (number five) could be your best option (you’re gone in a few seconds) or among your worst (you’re alive for years but unable to move or talk). Nevertheless, among the top five, cancer is clearly the one to avoid. Although often these days people are cured of cancer, the topic here is what kills you, and our premise is that something is going to kill you eventually (a premise with considerable data to back it up). Cancer, if it kills you, is not likely to do so gracefully.
Number fourteen on the government’s “best killer list” (as it is not called) is Parkinson’s disease. Of the 2.5 million who died of all causes in 2011, 23,000 died of Parkinson’s. This interested me, because I have Parkinson’s, and one of the first things you are told, at least if you are still middle-aged when you get the diagnosis (I was forty-two; now I’m sixty-five), is that you are not likely to die of it. It turns out that people do die of it, but rarely before very old age, even if they got the diagnosis when fairly young. In 2012, Parkinson’s killed another 23,000 Americans. But only 496 were in my fifty-five to sixty-four age group. By contrast, more than 9,000 were over the age of eighty-five. (This is encouraging: Not only do most people with Parkinson’s not die of it, but even of those who do, almost half make it past eighty-five.)
Parkinson’s is what happens when your brain stops producing enough dopamine. It entails a strange collection of symptoms that are distributed somewhat randomly among its victims. Almost no one has all of them. Everyone has some. It is classified as a “movement disorder,” and it certainly is that, though the disorder can take the form of stiffness approaching paralysis or shaking and exaggerated movements approaching an epileptic fit. And there are other symptoms, unrelated to movement, such as insomnia, depression, and bad skin. Some people with Parkinson’s have trouble walking through open doorways. (You have to back up and give yourself a running start.) The drugs you take to alleviate the symptoms have symptoms of their own, ranging from involuntary movements of various sorts to (my favorite) a compulsion to gamble.
Even two decades after I got the diagnosis, my symptoms are on the mild side, though no longer undetectable. They got even milder after I had an operation to implant wires in my brain and two pacemaker-like batteries in my chest. The batteries send pulses to a particular point in the brain that…well, I don’t really know much about how it works. But the result is that I take fewer pills than before and have much less “off” time, when the pills don’t work. The procedure, known as deep brain stimulation, or DBS, though no longer officially “experimental,” was still fairly exotic when I had it about a decade ago. As a treatment for Parkinson’s it has become almost commonplace since then. It has been tried on other ailments as well, including depression, obsessive-compulsive disorder, and even Tourette syndrome. (“No shit,” did I hear you say?) For each disease, doctors go for a different spot in the brain. It’s almost like phrenology reinvented, with the important difference that DBS works. My surgeon, Dr. Ali Rezai, then of the Cleveland Clinic, is a renowned pioneer in deep brain stimulation and a great enthusiast. I have joked with him that if I came to Ohio complaining of athlete’s foot, he’d know just the spot in my head where the wires should go.
During the operation, your head is screwed into a metal frame and the frame is screwed into the operating table. Some surgeons do it without the frame—certainly the most unpleasant part of the surgery—but this sounds to me like machismo (a professional deformity, as the French say, among neurosurgeons). Take my advice and let them screw your head to the table. My surgery lasted nine hours, and for most of it I had to be awake, so that the doctors could test the connection, like asking somebody to go upstairs and see if the light in the bedroom comes back on while you fiddle with the circuit-breaker box in the basement. It’s not fun, but it doesn’t hurt (your brain has no nerve endings for pain), and everything except the operation itself is sort of fun after all.
Immediately after surgery, all the symptoms of Parkinson’s disappear—even though the batteries aren’t turned on for a month. The very process of implanting the wires mimics the effect of the electricity from the batteries. Over the next two or three weeks, the old symptoms return. Then, when the batteries are turned on, the symptoms disappear or are reduced again. These results are instantaneous, though they vary from patient to patient, and it takes up to a year of visits, every month or so, to get the adjustment right.
Along with the benefits, there are some minor nuisances. At the airport, I am not supposed to go through the metal detector. Instead, I stand spread-eagled while the TSA man feels me all over, using (he assures me) the back of his hand for “sensitive areas.” I am supposed to keep my distance from refrigerator doors—especially those big, heavy Sub-Zero refrigerator doors that virtually symbolize yuppie desire—because they use strong magnets to stay shut, and these can interfere with the batteries. I can usually get a rise out of my wife by walking innocently past our refrigerator and pretending to be sucked toward and pinned against the doors. When I wanted some wireless earphones to use on the exercise machine, every brand I tried crackled with interference. I finally figured out why: my built-in antennae. This is all a small price to pay.
Everything about DBS is improving all the time. They now only need to install the battery on one side, not two. You do have to get the batteries replaced in a minor surgery every four or five years, but the new batteries apparently don’t interact with magnets, so you should be able to walk through airport security like a normal person—though they still advise against it.
The future for people with Parkinson’s is unclear but in a good way, because that future is getting better. New drugs are coming along all the time. The demographic power of the boomer generation, as it enters the Parkinson’s years, will spur more research and new therapies. And of course, there is the promise of DNA and stem cells.
The lost years are maddening, especially since the opposition to stem cell research, if it isn’t purely cynical, is based on a fundamental misunderstanding. The embryos used in stem cell research come from fertility clinics, where it is standard procedure to create more embryos than are needed and to dispose of the extras. (For that matter, this is not so different from standard procedure in the method of human reproduction devised by God as well, which relies on spontaneous abortions to weed out the weaker embryos.) Thousands of embryos live and die this way every year, and there is no fuss. Why don’t prominent politicians speak out against fertility clinics? If embryos are morally equal to children and adults, fertility clinics are slaughterhouses. President George W. Bush did discuss fertility clinics in his TV speech on stem cell research. He mentioned them in order to praise them for their contribution to human happiness. (In his speech, President Bush announced a ban on federally funded embryonic stem cell research. Obama restored the funding of stem cell research and ended the ban soon after taking office.) You cannot logically be against stem cell research on the ground that it encourages what happens in fertility clinics and yet be in favor of, or indifferent to, fertility clinics themselves. And yet for eight years, that was my country’s official position.
Even now that the ban is lifted, stem cell research is unlikely to develop fast enough to bail me out. Nevertheless, I’m optimistic. Unlike other neurological ailments such as epilepsy or multiple sclerosis, which entail flare-ups, Parkinson’s tends to advance at a steady pace (relentless, you might say). Factoring in other new treatments, and my good luck so far, I figure that my chance of being alive at eighty—fifteen years from now—is about as good as that of any other sixty-five-year-old American male. That chance is almost exactly fifty-fifty. And I’m more likely to be felled by a heart attack, just like my boomer buddies, than by Parkinson’s. On the other hand, the chance that I’ll be cross-country skiing in my eighties is small. Not that I ever did much cross-country skiing. One incidental benefit of Parkinson’s has been regular opportunities to ring changes on that old joke “Doctor, Doctor, will I be able to play the piano?” (Doctor: “Yes, certainly.” Patient: “Funny, I never could before.”) When it comes to having the tiniest telephone or the biggest refrigerator, I’m still in the game. But when it comes to the ultimate boomer game, competitive longevity, I’m on the sidelines doing color commentary. This is not because I’m more likely to keel over early but because having a chronic disease—or, more to the point, being known to have a chronic disease—automatically starts you on your expulsion from the club of the living.
Sometimes I feel like a scout from my generation, sent out ahead to experience in my fifties what even the healthiest boomers are going to experience in their sixties, seventies, or eighties. There are far worse medical conditions than Parkinson’s, and there are far worse cases of Parkinson’s than mine. But what I have, at the level I have it, is an interesting foretaste of our shared future—a beginner’s guide to old age.
Many of the symptoms of Parkinson’s disease resemble those of aging: a trembling hand, a shuffling gait, swallowing—or forgetting to swallow, or having trouble swallowing—a bewildering variety of pills. Of the half dozen or so main Parkinson’s drugs, the most effective by far goes by the trade name Sinemet. Its principal ingredient is levodopa, a chemical that turns into dopamine in the brain. Levodopa works differently for different people, and often stops working or develops intolerable side effects. But for me right now Sinemet’s effects last about four hours. During those four hours I go through the whole cycle of life, or at least the adult part. I take a pill and shortly feel as if I am twenty. My mood is sunny and optimistic, I move fluidly, I’m full of energy—I don’t know whether to go out and run a couple of miles or finish that overdue book review. This feeling lasts for a couple of hours, then starts to wear off. Another half hour, maybe, and I’m back where I belong, in middle age. Half an hour after that, I’m feeling old, stiff, tired, and gloomy. Then I pop another pill and the cycle starts all over.
I was around fifty when I went public about having Parkinson’s, and the effect was more like turning sixty. A person who is sixty and healthy almost surely will live many more years. But sixty is about the age when people stop being surprised if you look old or feel sick or drop dead. (It’s another decade or so before they stop pretending to be surprised.) It’s often said of people, “She’s a young seventy” or “He’s thirty, going on forty-five.” And it’s true: There is your actual, chronological age, and then there’s the age you see in the mirror, the age that reflects how you look, how you feel, how much hair you have left, how fast you can walk, or think, and so on. At every stage of life, some people seem older or younger than others of the same age. But only in life’s last chapter do the differences get enormous. We are not shocked to see a seventy-one-year-old hobbling on a cane, or bedridden in a nursing home, and we are not shocked to see a seventy-one-year-old running for president. The huge variety of possible outcomes—all of them falling within the range considered “normal”—makes the last boomer competition especially dramatic. So does the speed at which aging can happen. Sometimes it’s even instantaneous. Fall, break your hip, and add ten years. Do not pass Go, do not collect two hundred dollars. It’s easy to imagine two sixty-year-olds, friends all their lives. One looks older because he’s bald—no big deal. Ten years later, when they’re seventy, the bald one has retired on disability and moved into a nursing home. The other is still CEO, has left his wife for a younger woman, and, in a concession to age, takes a month off each year to ski. Contrasts like these will be common.
Almost 3 percent of Americans older than sixty-five are residents of nursing homes, and for those older than eighty-five the figure is just over 10 percent. The odds look reassuring—even among the very-oldsters, it’s only one out of ten. Trouble is, just being out of a nursing home doesn’t necessarily put you in a Mrs. McNamara Memorial Love Shack. Actual nursing homes are just the penultimate stop along a trail of institutions that we boomers have become familiar with—and try not to think about—in dealing with our parents. It starts with so-called independent living, and runs through assisted living to the nursing home, with possible detours through home health care and rehab, and thence to the hospital and points beyond. One admirable goal of these institutions is to ease the inevitable transition from active, contributing citizen to dependent, living off the financial and emotional acorns stored over a lifetime. But these institutions also announce that transition and push people along. Entering one of these places is entering a new phase of life as clearly as going away to college.
Decades before the nursing home, though, we all cross an invisible line. Most people realize this only in retrospect. If you have a chronic disease—even one that is slow-moving and nonfatal—you cross the line the moment you get the diagnosis. Suddenly, the future seems finite. There are still doors you can go through and opportunities you can seize. But every choice of this sort closes off other choices, or seems to, in a way that it didn’t use to. In every major decision—buying a house or a car, switching your subscription from Time to The Economist—you feel that this is the last roll of the dice. It needn’t be this way; in the more than twenty years since my own Parkinson’s was diagnosed, I’ve moved half a dozen times, changed jobs even more often, gotten married, let my New Yorker subscription lapse and then renewed it. Each change feels like an unexpected gift, or a coupon I’d better redeem before it expires.
This terror of being written off prematurely (like being buried alive) makes it difficult to write about a medical condition that may linger and get worse slowly for decades while you try to go about your life like a normal person. People say, in all kindness, “Hey, you look terrific,” which leaves you wondering what they were expecting, or how you looked the last time you saw them. They seem taken aback that you are around at all. The first time you hear or read a casual reference to “healthy persons,” it is a shock to realize that you are permanently disqualified for that label. And then you realize—even more shocking—that you’re the only one who’s shocked. Everyone else has adjusted, reassigned you, and moved on. Even if you feel fine, you walk around in an aura of illness.
By a weird coincidence, my aunt, who knows nothing about this book, sent me an artifact she’d come across in the process of moving my uncle and herself from the small house in Uniontown, Pennsylvania, where they had lived for decades and raised four children, into a gargantuan independent-living facility outside of Washington, DC, near some of her grandchildren. It is a letter I apparently sent to a cousin at age sixteen, filling her in on important developments. After describing possible summer jobs et cetera, the letter concludes, “I forgot to mention what’s really exciting. I can drive now! And I took the test on four hours’ sleep. Nothing else new.”
Driving makes you a grown-up. Precisely because you are trying to lead a normal life, and believe you are succeeding, the first really big shock, the first real change in your life and unambiguous message that you’re ill, comes when you are told that you have to give up driving. This changes your life dramatically—and not in a good way. The driving issue is one of the big ones between spouses, and between parents and adult children. Even if it comes when you’re in your late eighties, and even if you know it’s probably necessary, you resent it terribly. When it happens in your early sixties, it immediately drops a fence between you and all of your age-cohort friends. They can drive; you can’t. None of this is completely rational. Rationally, you should realize that the process of aging, with or without a major ailment, will gradually rob you of many things more important than your driver’s license. Still, it’s depressing to think of all the places you never went to because it seemed like too much trouble to drive there. Meanwhile, because your family and friends have most likely processed the fact of your health problems more thoroughly than you have, and have come to terms with them, which you haven’t, they can’t understand why you are so upset and resist so mightily. You’ve got Parkinson’s—did you think you’d never have to stop driving? Or, as the late Meg Greenfield put it, “Other people’s troubles are always easier to bear.”
In these family discussions, Granny is on the defensive. She is the one with the biggest incentive to ignore reality. Although I have stopped driving, at my wife’s insistence, I still believe that I’m a better driver than she is. But the thought of arguing about it, and the thought that one accident could prove me disastrously wrong, persuaded me to give in without much of a fight.
I’ve found what many people find who give up or curtail their driving, even those who do it with no medical compulsion: The combination of walking and public transport can get you where you need to go more cheaply than buying, maintaining, and fueling a car. It takes a bit longer—but often only a bit. It helps if you can afford to treat yourself to a taxi or Uber when necessary, or even when not necessary, just because you feel like it.
Rationally, giving up driving is one of the lesser deprivations that are imposed on people for one reason or another. In fact, it is one of the lesser sacrifices that you yourself will have to make as you get older. But it doesn’t feel that way when it hits you. As I say, this is partly because it is often the first big one. Also partly because a car represents freedom. But partly because a driver’s license represents adulthood, and full participation in adult life. Not being able to drive infantilizes.
Studies confirm the obvious: It’s depressing to stop driving. There is a correlation between Parkinson’s and depression anyway. Over half of all Parkinson’s patients are clinically depressed—and not just because it’s depressing in the nonscientific sense; there’s something chemical going on—they don’t know what. Add to this the conclusion of one study involving four thousand elderly men and women—that turning in your keys makes you 44 percent more likely to “experience increased depressive symptoms”—and you’ve got a fine formula for a pretty dismal Saturday night. Other studies of the perfectly obvious have concluded that people who give up driving have lower levels of life satisfaction than either those who are still driving or those few who never drove. That’s after correcting for age, medical condition, median time for a pizza to be delivered, and everything else. Big surprise.
People with Parkinson’s often develop a blank, unblinking stare known as “facial masking.” They also tend to mumble. Symptoms like these can lead friends and family to think that those with Parkinson’s are losing their wits. Cognitive problems affect an uncertain percentage of Parkinson’s victims, primarily those who get the disease late in life. But, as discussed in the next chapter, researchers have concluded that cognitive problems are more central to Parkinson’s than was previously believed.
Some researchers believe that “young onset” Parkinson’s, meaning diagnosed before the age of fifty, may be an entirely different disease. But of course you can’t count on everybody you meet in a day being totally up to speed on the latest research about a disease they don’t have. The familiar dream that you are in the middle of an exam you haven’t prepared for has some basis in reality for a person with Parkinson’s, just as it must for many people in their seventies and for almost all those in their eighties. In every social encounter, you’re being observed and assessed. Twenty years ago I was described in a New Yorker profile as having “a languid, professorial air…his arms stiffly by his side; his eyes seem stretched open, for he seldom blinks, and…[he] speaks slowly, deliberately, quietly [with] parsimonious gestures.” Since I’ve gone public, no one has suggested that these symptoms add up to looking “professorial.”
For a yuppie careerist, the first painful recognition that you have crossed an invisible line from being healthy to being sick probably comes at work. You’ve done fine, and your boss and coworkers have been as sympathetic as you let them be, but guess what? You’ve had your last promotion. You will not be chair of the company, or editor of the newspaper, or president of the university. To be sure, it’s mathematically inevitable that for every CEO there will be half a dozen vice presidents whose careers will seem successful enough to everybody but themselves. Nevertheless, to them the realization that they won’t make it all the way to the tippy-top is poignant. For someone with a chronic disease, it’s slightly different. It’s not that the arc of your career never quite reached the apogee that you hoped for. It’s that the arc was unexpectedly chopped off. (Why that should seem more unfair, I cannot say. But it does.) For most people the realization comes when somebody younger gets a job that they covet. For the person with a chronic disease, it’s when somebody older than you gets the job. You’re over. He’s still a player. He wins.
Timing is everything. Shortly after becoming chief justice, John Roberts had the second of what appeared to be epileptic seizures. The first had occurred fourteen years earlier. No one even suggested that he should have to resign from the court. But do you think President Bush would have nominated Roberts if the second seizure had already occurred? Unlikely. Why risk it?
It is a treasured corollary of the American Dream that most people who are successful in midlife were losers in high school. As you enter adult life, values change and the deck is reshuffled. You get another chance and maybe, if you’re lucky, the last laugh. But it isn’t the last laugh. The deck is shuffled again as you enter the last chapter. How long you live, how fast you age, whether you win or lose the cancer sweepstakes or the Parkinson’s bingo—all these have little to do with the factors that determined your success or failure in the previous round. And there is justice in that.
Some people win two rounds, or even all three. But they, too, cross that invisible line at some point. Old soldiers aren’t the only ones who just fade away. What ever happened to Robert McNamara anyway?